Hepatitis A Information

Subscribe to Hepatitis A Information

Patrons who ate at Hardees restaurant on Little Rock Road in Charlotte between June 13 and 23 should receive a hepatitis A vaccination as soon as possible.

Public Health Director Gibbie Harris announced today that the outbreak identified by the State and Centers for Disease Control (CDC) earlier this month in Mecklenburg County has led to five additional cases since June 6, including a Hardees employee diagnosed Monday.

“After consulting with the State today, we are recommending a vaccination for exposed employees and patrons who ate at the 2604 Little Rock Road location between June 13 and 23,” Harris said. “According to the CDC, the vaccine must be given within 14 days of exposure for the vaccine to be effective.”

Public Health vaccination clinics for customers who might have been exposed and for residents who meet the high-risk factors for hepatitis A will be held:

  • Wednesday, June 27 from 8 a.m. – 7.p.m, and Thursday, June 28 from 8 a.m. – 5 p.m., at Northwest Health Department, 2845 Beatties Ford Rd. and Southeast Health Department, 249 Billingsley Rd., Charlotte.
  • Friday, June 29 from 3 p.m. – 8p.m. at the Hal Marshall Building, 700 N. Tryon St., Charlotte.
  • Saturday, June 30 and Sunday, July 1 from 10 a.m. – 3 p.m. at the Hal Marshall Building, 700 N. Tryon St, Charlotte.

People who dined at Hardees on Little Rock Road on June 13 and 14 are strongly urged to get a vaccination in the next two days.

Public Health announced June 6 that North Carolina Public Health officials and the CDC declared an outbreak of the liver disease in Mecklenburg County. Five additional cases of hepatitis A have been identified for a total of ten confirmed cases since April 20. Those who have had a hepatitis A infection, or one hepatitis A vaccination, are protected from the virus and do not need to take action.

The high-risk factors include:

  • Those who are household members, caregivers, or have sexual contact with someone who is infected with hepatitis A
  • Men who have sexual encounters with other men
  • Those who use recreational drugs, whether injected or not
  • Recent travel from countries where hepatitis A is common
  • Homeless individuals who do not have easy access to handwashing facilities

The best ways to prevent hepatitis A include:

  • Get the hepatitis A vaccine;
  • Practice safe handwashing procedures – wash your hands under warm, soapy water for at least 20 seconds after using the bathroom or changing diapers and before you prepare food, and
  • Wear a condom during sexual activity.

Public Health staff continues to work with medical providers and community partners to educate residents about how to prevent hepatitis A and to implement a plan to educate and encourage vaccination of those most at-risk of contracting the virus.

Since 2012, hepatitis A virus cases have been on the rise across the country. Between July 2016 to November 2017, the CDC reports 1200 cases have occurred nationally, including 826 hospitalizations and 37 deaths.  Outbreaks have occurred in California, Utah, Kentucky, Michigan, Indiana, and West Virginia.

What to know about hepatitis A

  1. It’s a highly contagious liver disease caused by a virus spread from person to person. The illness can last for weeks to months. Only acute cases are reportable in North Carolina.
    2. Hepatitis A spreads through the fecal-oral route, most commonly by forgetting to wash your hands after using the bathroom or changing diapers, having sexual contact with infected partners and eating or drinking foods contaminated by hepatitis A.
    3. Hepatitis A symptoms include nausea, fever, yellowing of the eyes and skin, dark urine, grey feces, joint pain, feeling tired, loss of appetite and stomach pain.
    4. The best way to prevent hepatitis A is to get the hepatitis A vaccine and to practice safe handwashing procedures – wash your hands under warm, soapy water for at least 20 seconds after using the bathroom or changing diapers and before you prepare food.
    5. Again, the most at-risk groups for hepatitis A are people who come into contact with someone who has hepatitis A, travelers to countries where hepatitis A is common, men who have sexual contact with men, people who use drugs (both injection and non-injection) and people with clotting factor disorders.

If you have potentially been exposed to hepatitis A and are unable to receive the vaccine watch for the symptoms listed above.  If you experience any of these symptoms, access medical care as soon as possible.

Hardee’s may be found at fault for allowing an employee to work while infected with HAV, for failing to properly supervise, train, or monitor their employees who prepare food for consumption, or for failing to require its food-service employees to obtain HAV immunizations.

Bill Marler, foodborne illness expert and food safety attorney, has been an avid advocate for strengthening preventative measures within the food industry. “Any exposure to hepatitis A is entirely preventable,” Marler said. “By not requiring employees to be vaccinated against the virus, Hardee’s puts itself and all of its customers at risk. Infected people typically don’t show symptoms until a few weeks after contracting hepatitis A, so they could be spreading the virus without even knowing it. However,” he continued, “Had all employees been vaccinated, Hardee’s wouldn’t have to worry about identifying HAV positive employees in the first place, and customers wouldn’t be panicking now to receive treatment.”

Exposed employees and customers are filing for damages that include wage loss, medical-related expenses, travel expenses, emotional distress, fear of harm and humiliation, and physical pain and injury.

The acute symptoms of hepatitis A are a sudden onset of flu-like symptoms about a month after the virus is contracted. Muscle aches, headaches, loss of appetite, abdominal discomfort, fever, and jaundice are all typical symptoms of the infection. Urine may turn a dark color and stool could be light or clay-colored. The illness typically lasts a few weeks, but recovery could take up to a year. Most affected individuals show complete recovery within three to six months of the onset of illness. Relapse is possible, although it is more common in children than adults.

The best protection against a hepatitis A infection is to get vaccinated. An estimated 80,000 cases of HAV occur each year, although much higher estimates have been proposed. Hepatitis A is a virus that primarily infects the liver, and an estimated 100 people die each year as a result of acute liver failure in the U.S. due to hepatitis A. However, the rate of infection has dramatically decreased since the hepatitis A vaccine was licensed and became available in the U.S. in 1995.

Because HAV is so readily transmitted, Bill Marler encourages restaurants and food handlers to adhere to strict sanitary protocols. He warns, “The virus is almost exclusively transmitted through fecal-oral contact, so it is crucial that all employees thoroughly wash their hands after using the restroom, whether they feel sick or not.” For more information about hepatitis A, please visit www.about-hepatitis.com.

State laboratory tests confirmed this week that five cases of the Hepatitis A virus reported in Northern Lower Michigan have officially been linked to the larger Southeast Michigan Outbreak of Hepatitis A. Four of these cases have been reported in Grand Traverse County and one in Leelanau County.

Since August 1, 2016, there have been 677 cases of Hepatitis A identified across the state, primarily in southeastern Michigan. 82% of the cases have been severe enough to lead to hospitalization. Both the Grand Traverse County Health Department and the Benzie-Leelanau Health Department are working with state officials and participating in the State’s Community Health Emergency Coordination Center (CHECC) to monitor Hepatitis A cases, as well as spread awareness about Hepatitis A in our community.

Hepatitis A can be a serious and contagious liver disease. Although not all people infected with the Hepatitis A virus experience illness, symptoms can include: nausea and vomiting, abdominal pain, feeling tired/fatigue, fever, joint pain, loss of appetite
, yellowing of the skin and eyes dark urine and 
pale-colored feces.

Hepatitis A virus often spreads by eating contaminated food or water, between sexual partners, or through close personal contact while living with an infected person. Individuals that are at a higher risk for getting the Hepatitis A virus include the following: the homeless or those living with transient housing, persons who are incarcerated, illicit drug users (both injection and non-injection drugs), persons who have sexual activities with someone infected with Hepatitis A virus, men who have sexual relations with men, and persons who have close contact, care for, or live with someone who has the Hepatitis A virus.

The Hepatitis A virus is vaccine preventable. While the vaccine is recommended as a part of the routine childhood vaccination schedule, many adults have not yet been vaccinated. “We recommend that everyone be vaccinated against Hepatitis A,” said Wendy Hirschenberger, Health Officer for Grand Traverse County Health Department. The best way to reduce the risk of getting Hepatitis A is to get vaccinated. It is also recommended to regularly wash your hands after using the bathroom and before preparing meals for yourself and others. In addition, don’t share toothbrushes or eating utensils, do not have sex with someone who has a Hepatitis A infection, and do not share food and/or drinks with other people.

Individuals who believe they have been exposed to Hepatitis A or who have symptoms consistent with the virus, should contact their healthcare provider immediately. Anyone who wants to be vaccinated should contact their healthcare provider or their local health department: Benzie-Leelanau Health Department at 231-256-0200 Grand Traverse County Health Department at 231-995-6131 Health Department of Northwest Michigan 800-432-4121

The confirmation of five cases of Hepatitis A in northern Michigan has prompted the Grand Traverse County Health Department to host special clinic hours to offer vaccinations to the community today (Saturday) from 10am to 1pm at the department’s offices at 2600 LaFranier Road.

The vaccination will be offered to individuals with or without insurance; those who can’t afford the vaccination or don’t have insurance can receive it for free. Hepatitis A is a serious, highly contagious liver disease caused by the Hepatitis A virus (HAV). The virus can be spread through contaminated food or water, sexual contact, or by living with an infected person. The illness can appear 15-50 days after exposure and last for several weeks. In some cases, Hepatitis A can be fatal.

Other upcoming extended clinic walk-in hours for vaccinations at the Grand Traverse County Health Department include:

Wednesday, February 21: 4:30pm-6:30pm
Wednesday, February 28: 7am-8am
Wednesday, March 7: 4:30pm-6:30pm
Wednesday, March 14: 7am-8am
Wednesday, March 21: 4:30pm-6:30pm
Wednesday, March 28: 7am-8am

The Wyoming Department of Health (WDH) and the Casper-Natrona County Health Department continue to investigate a growing Natrona County hepatitis A outbreak that began in October.

Since October, 14 cases have been confirmed among Natrona County residents, which is a significant increase over the usual total for Wyoming. Previously, the long-term average statewide was two cases annually with the last reported local Hepatitis A infection in 2012.

“While some of the Natrona County cases did not have a clear hepatitis A exposure risk, recent cases have been concentrated among current injection drug users,” said Clay Van Houten, Infectious Disease Epidemiology Program manager with WDH.

Infection with hepatitis A typically results in symptoms in older children and adults.

Symptoms usually occur abruptly and include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored stools, joint pain and jaundice.

There can be a significant delay between when someone who is exposed to the virus and when they show symptoms.

“People recently exposed to hepatitis A who have not been vaccinated should receive a vaccine as soon as possible,” Van Houten said.

Specific risk factors for hepatitis A include:

  • Persons with direct contact with a person who has hepatitis A
  • Men who have sex with men
  • Users of injection and non-injection drugs
  • Travelers to countries with high rates of hepatitis A infectionHepatitis A can cause infection in the liver. The virus is primarily spread person-to-person through oral contact with contaminated items such as swallowing food or drink tainted with a tiny amount infected feces.

Van Houten said the best way to prevent hepatitis A is through vaccination.

Handwashing, especially after using the bathroom, changing diapers, and before preparing or eating food, plays an important role in preventing the spread of the virus.

Vaccination to prevent hepatitis A is routinely recommended.

Children aged at least 12 months and less than 24 months should receive two doses of the vaccine separated by at least 6 months and no less than 18 months.

The vaccine series is also recommended for people aged 2 years or older who have not already received it.

The Casper-Natrona County Health Department offers the hepatitis A series vaccine; some people may qualify for free or discounted vaccine.

The Detroit Health Department recommends all food establishments get their employees vaccinated.

To support this effort, the Detroit Health Department is launching a mobile vaccination clinic program to provide easy and convenient access for Detroit food establishments to vaccinate their employees.

The Department will set up clinics throughout the City of Detroit, where clusters of restaurants are located.

Restaurants can call the Detroit Health Department at 313-876-0135 to arrange for vaccination.

Southeast Michigan has seen 692 hepatitis A cases, with 564 hospitalizations resulting in 22 deaths in the last year.

Hepatitis A is a contagious liver disease that results from infection with the Hepatitis A virus. It can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months. Hepatitis A is usually spread when a person ingests fecal matter — even in microscopic amounts — from contact with objects, food, or drinks contaminated by the feces, or stool, of an infected person.

Likely Linked to broader hepatitis A outbreak in area.

Salt Lake County Health Department (SLCoHD) announced today that customers of the 7-Eleven convenience store at 2666 West 7800 South in West Jordan who used the restroom at the store or consumed certain items on specific dates should contact the health department for information about receiving an injection to prevent hepatitis A. This possible exposure affects only this single 7-Eleven location.

The preventive injection recommendation is for customers who visited the store on any date from Tuesday, December 26, through Wednesday, January 3, and who used any restroom in the store or consumed any of the following items:

  • Fountain drink or other self-serve beverage
  • Fresh fruit
  • Any item from the store’s hot food case, such as pizza, hot dogs, chicken wings, or taquitos

Packaged items, including bottled beverages and microwaved foods, are NOT implicated in the possible exposure. Customers who consumed only packaged or bottled items do not need to contact the health department. Customers who are fully vaccinated (two doses) against hepatitis A also do not need to contact the health department.

Customers who used the store restroom or consumed any of the items listed above on any of the dates indicated should call 385-468-INFO (4636) for further instructions. The phone line will be staffed form 8:00 a.m. to 5:00 p.m. beginning Monday, January 8. Health department staff will screen callers for their exposure risk and provide them with options for receiving a prophylactic hepatitis A vaccine.

People in need of prophylaxis must receive it within a short time period of their possible exposure, so it is essential that affected customers call the health department as soon as possible. Based on average sales volume for this store, health officials estimate up to 2,000 customers may be affected.

The possible hepatitis A exposure occurred when an infected employee worked while ill and potentially handled certain items in the store. SLCoHD believes this case is linked to the ongoing outbreak Salt Lake County has been experiencing since August 2017. 7-Eleven is cooperating fully with the health department’s investigation and response and, since discovering the possible exposure, has sanitized the affected store according to health department recommendations.

“This is an important reminder to food service establishments that they should consider vaccinating their food-handling employees against hepatitis A,” said Gary Edwards, SLCoHD executive director. “It’s also important that food handlers be conscientious with hygiene, hand washing and not working when ill—and that managers be vigilant in enforcing those important requirements that help protect public health.”

Hepatitis A vaccine is covered by most insurance plans and is widely available at local pharmacies, health care providers and SLCoHD immunization clinics. Call 385-468-SHOT (7468) for an appointment at a health department immunization clinic.

Since January 1, 2017, Utah public health has identified 141 confirmed cases of hepatitis A virus (HAV) infection; many among persons who are homeless and/or using illicit drugs. Several cases have been linked by investigation and/or viral sequencing to a national outbreak of hepatitis A involving cases in California and Arizona. Hospitalization rates of less than 40% have been described in previous hepatitis A outbreaks; however, other jurisdictions associated with this outbreak are reporting case hospitalization rates approaching 70%. The high rate of hospitalization may be a result of cases having underlying illnesses (e.g., alcoholism), or a higher rate of hepatitis comorbidities (e.g., hepatitis B or C). In response to the outbreak, public health officials have been working to identify cases and contacts, provide education, and ensure opportunities for vaccination of close contacts to cases and vulnerable populations.

Hepatitis A is usually spread through having oral contact with items contaminated with hepatitis A, for example, through ingesting food or drinks contaminated by infected feces. Some people do not develop symptoms, even if infected. If symptoms occur, they usually appear anywhere from 2-6 weeks after exposure. Symptoms usually develop over a period of several days, and may include jaundice (the yellowing of the skin or whites of the eyes), abdominal pain, nausea or diarrhea. Hepatitis A vaccination is the best way to prevent hepatitis A infection.

Thanks to HepMag.com for a great summary of ongoing hepatitis A outbreaks going on in the US.

California

Public health officials first detected the hepatitis A outbreak in November 2016 and as of July 21, 2017, 251 cases and 5 deaths have been reported in San Diego. Those affected have largely been homeless individuals, which has made public health efforts more challenging to implement, particularly in reaching individuals with vaccinations and improving hygiene practices. Local officials and community organizations have been working to raise awareness of hepatitis A vaccination, distribute “Hepatitis A Prevention Kits” (containing sanitary supplies), and plans are underway to install hand-washing stations in areas frequented by homeless persons to help stop the spread. Since the outbreak began, the county has administered over 4,000 hepatitis A vaccinations, and more work is planned to expand those efforts. With this combined approach, San Diego is hoping to end the outbreak, the largest in California in nearly 20 years.

Colorado

Between January and early July 2017, 43 cases of hepatitis A were reported in Colorado, a significant increase from 2016 where 23 cases were reported for the full year. Half of these cases resulted in hospitalization and one person has died. Unlike many hepatitis A outbreaks, there is no apparent common link to a restaurant or food item. 74% of hepatitis A cases are men and at least half are men who have sex with men (MSM). Local public health agencies are working to battle the epidemic by targeting MSM with outreach and offering vaccination at a variety of sites.

Michigan

Between August 2016 and June 2017 in southeast Michigan, almost 200 people have been diagnosed with hepatitis A infection, 90% of those infected have required hospitalization, and 10 people have died. Public health officials believe the outbreak to be unrelated to water or food contamination, but rather person-to-person spread through use of illicit drugs, sexual contact, and close proximity. Nearly 50% of those infected report a history of substance use disorders and 20% are also infected with hepatitis C.

A comprehensive hepatitis A vaccination program established in Alaska in the 1990s, which became a requirement for school entry in 2001, has virtually wiped out the virus in the native peoples of Alaska, where it had been endemic.

Data from the program is being presented at this year’s World Indigenous Peoples’ Conference on Viral Hepatitis in Anchorage, Alaska, USA (8-9 August) by Stephanie Massay, Epidemiology Specialist with the Alaska Division of Public Health, Section of Epidemiology, Anchorage, AK, USA, and colleagues.

Hepatitis A is an acute (short-term but severe) infection of the liver caused by the hepatitis A virus. Fever, weakness, nausea, aches and pains, and jaundice can be among the symptoms experienced. The hepatitis A virus can survive in the environment on and in food. It is also relatively resistant to detergents but can be inactivated by high temperature (85°C or higher) and by chemicals such as chlorine. Although it occurs worldwide, HAV occurs more commonly in populations with poor sanitation, such as poor populations in developed countries (e.g. Indigenous populations) and also in developing countries more generally.

Alaska experienced epidemics of hepatitis A every 10-15 years during the 1950s to the 1990s, resulting in thousands of cases. Alaska Native (AN) people living in rural communities were disproportionately impacted.

Hepatitis A virus (HAV) vaccines were licensed in 1995 and recommended by the Advisory Committee on Immunization Practice (ACIP) for routine vaccination of US children in populations with high HAV infection rates. Alaska began universal vaccination for children aged 2-14 years in 1996? HAV vaccination became required for school entrance in 2001. In 1997, following ACIP recommendations, this was expanded to include all children age 2 – 18 years, and in 2006 this was further expanded to include children age 1 – 18 years.

The data showed that during 1972-1995, Alaska’s average annual incidence of hepatitis A was 60 per 100,000 population. Rates by race were substantially higher for AN people compared to non-AN people (244 vs 19 per 100,000 respectively, with AN people being 13 times more likely to be infected than non-AN people).

Compared to 1972-1995 (pre-vaccine), 2002-2007 (post­vaccine) statewide hepatitis A incidence fell by 98% (0.9 vs. 60 per 100,000); among AN peoples the incidence fell by 99.9% (0.3 vs. 243.8 per 100,000). During 2008-2016, 23 HAV cases were reported in Alaska? 5 among AN, 11 among non­AN, and 7 among people of unknown race/ethnicity.

The 2008-2016 statewide incidence of hepatitis A was 0.35 cases per 100,000 people? the incidence in children aged <14 years was 0.14 cases per 100,000 children. Of the 17 cases with documentation on travel, 15 (88%) had recent travel outside of Alaska. In 2015, National Immunization Survey data estimated that among children aged 19-35 months, HAV vaccine coverage was similar in Alaska (84%) and all US children (86%).

The authors conclude: “Dramatic declines in the incidence of hepatitis A occurred after HAV vaccine was recommended as a routine childhood vaccine and after it was required for school entry. Prior to routine vaccination, most the reported HAV cases were associated with outbreaks occurring within Alaska. Since 2008 however, 88% of reported hepatitis A cases have been imported, many of which were acquired during travel outside of the United States.”

THE HEPATITIS A VIRUS

Exposure to hepatitis A virus (“HAV”) can cause an acute infection of the liver that is typically mild and resolves on its own.[1] The symptoms and duration of illness vary a great deal, with many persons showing no symptoms at all.[2] Fever and jaundice are two of the symptoms most commonly associated with HAV infection.[3]

Throughout history, hepatitis infections have plagued humans. The “earliest accounts of contagious jaundice are found in ancient China.”[4] According to the CDC:

The first descriptions of hepatitis (epidemic jaundice) are generally attributed to Hippocrates. Outbreaks of jaundice, probably hepatitis A, were reported in the 17th and 18th centuries, particularly in association with military campaigns. Hepatitis A (formerly called infectious hepatitis) was first differentiated epidemiologically from hepatitis B, which has a long incubation period, in the 1940s. Development of serologic tests allowed definitive diagnosis of hepatitis B. In the 1970s, identification of the virus, and development of serologic tests helped differentiate hepatitis A from other types of non-B hepatitis.[5]

Until 2004, HAV was the most frequently reported type of hepatitis in the United States. In the pre-vaccine era, the primary methods used for preventing HAV infections were hygienic measures and passive protection with immune globulin (IG). Hepatitis A vaccines were licensed in 1995 and 1999. These vaccines provide long-term protection against HAV infection.[6

Hepatitis A is the only common vaccine-preventable foodborne disease in the United States.[7] This virus is one of five human hepatitis viruses that primarily infect the human liver and cause human illness.[8] Unlike hepatitis B and C, hepatitis A does not develop into chronic hepatitis or cirrhosis, which are both potentially fatal conditions.[9] Nonetheless, infection with the hepatitis A virus (HAV) can lead to acute liver failure and death.[1

Where does Hepatitis A Come From?

Hepatitis A is a communicable (or contagious) disease that often spreads from person to person.[11] Person-to-person transmission occurs via the “fecal-oral route,” while all other exposure is generally attributable to contaminated food or water.[12] Food-related outbreaks are usually associated with contamination of food during preparation by a HAV-infected food handler.[13] The food handler is generally not ill because the peak time of infectivity—that is, when the most virus is present in the stool of an infected individual—occurs two weeks before illness begins.[14]

Fresh produce contaminated during cultivation, harvesting, processing, and distribution has also been a source of hepatitis A.[15] In 1997, frozen strawberries were the source of a hepatitis A outbreak in five states.[16] Six years later, in 2003, fresh green onions were identified as the source of a HAV outbreak traced to consumption of food at a Pennsylvania restaurant.[17] Other fruits and vegetables, such as blueberries and lettuce, have also been associated with HAV outbreaks in the U.S. as well as in other developed countries.[18] HAV is relatively stable and can survive for several hours on fingertips and hands and up to two months on dry surfaces.[19] The virus can be inactivated by heating to 185°F (85°C) or higher for one minute, or disinfecting surfaces with a 1:100 dilution of household bleach in tap water.[20] HAV can still be spread from cooked food if it is contaminated after cooking.[21]

Although ingestion of contaminated food is a common means of spread for HAV, it may also be spread by household contact among families or roommates, sexual contact, or by direct inoculation from persons sharing illicit drugs.[22] Children are often asymptomatic, or have unrecognized infections, and can pass the virus through ordinary play, unknown to their parents, who may later become infected from contact with their children.[23]

What are the Symptoms of Hepatitis A?

Hepatitis A may cause no symptoms at all when it is contracted, especially in children.[24] Asymptomatic individuals will only know they were infected (and have become immune, given that you can only get hepatitis A once) by getting a blood test later in life.[25] Approximately 10 to 12 days after exposure, HAV is present in blood and is excreted via the biliary system into the feces.[26] Although the virus is present in the blood, its concentration is much higher in feces.[27] HAV excretion begins to decline at the onset of clinical illness, and decreases significantly by 7 to 10 days after onset of symptoms.[28] Most infected persons no longer excrete virus in the feces by the third week of illness. Children may excrete HAV longer than adults.[29]

Seventy percent of HAV infections in children younger than six years of age are asymptomatic; in older children and adults, infection tends to be symptomatic with more than 70% of those infected developing jaundice.[30] Symptoms typically begin about 28 days after contracting HAV, but can begin as early as 15 days or as late as 50 days after exposure.[31] The symptoms include muscle aches, headache, anorexia (loss of appetite), abdominal discomfort, fever, and malaise.[32]

After a few days of typical symptoms, jaundice (also termed “icterus”) sets in.[33] Jaundice is a yellowing of the skin, eyes, and mucous membranes that occurs because bile flows poorly through the liver and backs up into the blood.[34] The urine will also turn dark with bile and the stool light or clay-colored from lack of bile.[35] When jaundice sets in, initial symptoms such as fever and headache begin to subside.[36]

In general, symptoms usually last less than two months, although 10% to 15% of symptomatic persons have prolonged or relapsing disease for up to 6 months.[37] It is not unusual, however, for blood tests to remain abnormal for six months or more.[38] The jaundice so commonly associated with HAV can also linger for a prolonged period in some infected persons, sometimes as long as eight months or more.[39] Additionally, pruritus, or severe “itchiness” of the skin, can persist for several months after the onset of symptoms. These conditions are frequently accompanied by diarrhea, anorexia, and fatigue.[40]

Relapse is possible with hepatitis A, typically within three months of the initial onset of symptoms.[41] Although relapse is more common in children, it does occur with some regularity in adults.[42] The vast majority of persons who are infected with hepatitis A fully recover, and do not develop chronic hepatitis.[43] Persons do not carry HAV long-term as with hepatitis B and C.[44]

Fulminant Hepatitis A

Fulminant hepatitis A, or acute liver failure, is a rare but devastating complication of HAV infection.[45] As many as 50% of individuals with acute liver failure may die or require emergency liver transplantation.[46] Elderly patients and patients with chronic liver disease are at higher risk for fulminant hepatitis A.[47] In parallel with a declining incidence of acute HAV infection in the general population, however, the incidence of fulminant HAV appears to be decreasing.[48]

HAV infects the liver’s parenchymal cells (internal liver cells).[49] Once a cell has been penetrated by the viral particles, the hepatitis A releases its own toxins that cause, in essence, a hostile takeover of the host’s cellular system.[50] The cell then produces new viral components that are released into the bile capillaries or tubes that run between the liver’s parenchymal cells.[51] This process results in the death of liver cells, called hepatic necrosis.[52]

The fulminant form of hepatitis occurs when this necrotic process kills so many liver cells—upwards of three-quarters of the liver’s total cell count—that the liver can no longer perform its job.[53] Aside from the loss of liver function, fulminant hepatic failure can lead to encephalopathy and cerebral edema.[54] Encephalopathy is a brain disorder that causes central nervous system depression and abnormal neuromuscular function.[55] Cerebral edema is a swelling of the brain that can result in dangerous intracranial pressure.[56] Intracranial hypertensions leading to a brain stem death and sepsis with multiple organ failure are the leading causes of death in individuals with fulminant hepatic failure.[57]

Incidence of Hepatitis A Infection

Hepatitis A is much more common in countries with underdeveloped sanitation systems and, thus, is a risk in most of the world.[58] An increased transmission rate is seen in all countries other than the United States, Canada, Japan, Australia, New Zealand, and the countries of Western Europe.[59] Nevertheless, infections continue to occur in the United States, where approximately one-third of the population has been previously infected with HAV.[60]

Each year, approximately 30,000 to 50,000 cases of hepatitis A occur in the United States.[61] Historically, acute hepatitis A rates have varied cyclically, with nationwide increases every 10 to 15 years.[62] The national rate of HAV infections has declined steadily since the last peak in 1995.[63] Although the national incidence—1.0 case per 100,000 population—of hepatitis A was the lowest ever recorded in 2007, it is estimated that asymptomatic infections and underreporting kept the documented incidence-rate lower than it actually is. In fact, it is estimated that there were 25,000 new infections in 2007.[64]

In 2007, the CDC reported a total of 2,979 acute symptomatic cases of HAV.[65] Of these, information about food and water exposure was known for 1,047 cases, leading to an estimate that 6.5% of all infections were caused by exposure to contaminated water or food.[66] In 2,500 of the cases, no known risk factor was identified.[67]

Estimates of the annual costs (direct and indirect) of hepatitis A in the United States have ranged from $300 million to $488.8 million in 1997 dollars.[68] Nationwide, adults who become ill miss an average of 27 workdays per illness, and 11 to 22 percent of those infected are hospitalized.[69] All of these costs are entirely preventable given the effectiveness of a vaccination in providing immunity from infection.[70]

[1]           Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” in Mandell, Douglas, & Bennett’s PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES, Fifth Edition, Chap. 161, pp. 1920-40 (2000); Mayo Clinic Staff, “Hepatitis A,” (last updated Sept 1, 2011). Articles available online at http://www.mayoclinic.com/health/hepatitis-a/DS00397.

[2]           Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[3]           Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[4]           Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[5]           CDC, “Hepatitis A,” in EPIDEMIOLOGY AND PREVENTION OF VACCINE-PREVENTABLE DISEASES (also known as “The Pink Book”), Atkinson W, Wolfe S, Hambrosky J, McIntyre L, editors, 12th edition. Chapter available online at http://www.cdc.gov/vaccines/pubs/pinkbook/hepa.html.

[6]           Id.

[7]           Id.; See also Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” Clinical Infectious Diseases, Vol. 38, 705-715 (March 1, 2004). Full text online at http://www.cdc.gov/hepatitis/PDFs/fiore_ha_transmitted_by_food.pdf.

[8]           Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[9]           Id.

[10]          Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[11]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[12]          Id.; See also Jaykus Lee Ann, “Epidemiology and Detection as Options for Control of Viral and Parasitic Foodborne Disease,” Emerging Infectious Diseases, Vol. 3, No. 4, pp. 529-39 (October-December 1997). Full text of the article is available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640072/pdf/9366607.pdf

[13]          Fiore, Anthony, supra note 7; CDC, “Hepatitis A,” supra note 5; See also CDC, “Surveillance for Acute Viral Hepatitis – United States, 2007, Morbidity and Mortality Weekly Report, Surveillance Summaries, Vol. 58, No. SS03 (May 22, 2009) at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5803a1.htm.

[14]          Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7.

[15]          Id.; See also, Wheeler, C, et al., “An Outbreak of Hepatitis A Associated with Green Onions,” New England Journal of Medicine, Vol. 353, 890-97 (2005). Full text of article available at http://www.nejm.org/doi/full/10.1056/NEJMoa050855.

[16]          Hutin YJF, et al., “A Multistate, Foodborne Outbreak of Hepatitis A,” New England Journal of Medicine, Vol. 340, pp. 595-602 (1999). Full text of article is online at http://nejm.org/doi/full/10.1056/NEJM199902253400802.

[17]          Wheeler, C, et al., “An Outbreak of Hepatitis A Associated with Green Onions,” supra note 15.

[18]          Butot S, et al., “Effects of Sanitation, Freezing and Frozen Storage on Enteric Viruses in Berries and Herbs,” Intentional Journal of Food Microbiology, Vol. 126, No. 4, pp. 233-246 (2003). Full text of article is available at http://www.prograd.uff.br/virologia/sites/default/files/bulot_et_al_2008_inactivation.pdf.; Calder, L, et al., An Outbreak of Hepatitis A Associated with Consumption of Raw Blueberries,” Epidemiology and Infection, Vol. 131, No. 1 745-51 (2003) at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870016/pdf/12948375.pdf.

[19]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[20]          CDC, “Updated recommendations from Advisory Committee on Immunization Practices (ACIP) for use of hepatitis A vaccine in close contacts of newly arriving international adoptees,” Morbidity and Mortality Weekly Report, Vol. 58, No. 36,  (Sept. 18, 2006), http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5836a4.htm; Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations, Morbidity & Mortality Weekly Review, Vol. 55, Report 407, (May 29, 2006) at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm; Todd, Ewan C.D., et al., “Outbreaks Where Food Workers Have Been Implicated in the Spread of Foodborne Disease. Part 6. Transmission and Survival of Pathogens in the Food Processing and Preparation-environment,” Journal of Food Protection, Vol. 72, 202-19 (2009). Full text of the article is available online at http://courses.washington.edu/eh451/articles/Todd_2009_food%20processing.pdf.

[21]          Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7.

[22]          Id.; See also, Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[23]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Piazza, M, et al., “Safety and Immunogenicity of Hepatitis A Vaccine in Infants: A Candidate for Inclusion in Childhood Vaccination Program,” Vol. 17, pp. 585-588 (1999). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/10075165; Schiff, E.R., “Atypical Manifestations of hepatitis-A,” Vaccine, Vol. 10, Suppl. 1, pp. 18-20 (1992). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/1475999.

[24]          Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7

[25]          Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[26]          CDC, “Hepatitis A,” supra note 5; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1

[27]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1

[28]          Id.

[29]          Id.; See also Sagliocca, Luciano, et al., “Efficacy of Hepatitis A Vaccine in Prevention of Secondary Hepatitis A Infection: A Randomized Trial,” Lancet, Vol. 353, 1136-39 (1999). Abstract at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)08139-2/abstract.

[30]          CDC, “Hepatitis A,” supra note 5.

[31]          Id.; See also Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7.

[32]          CDC, “Hepatitis A,” supra note 5; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[33]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[34]          Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[35]          CDC, “Hepatitis A,” supra note 5; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[36]          Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[37]          Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations,” supra note 20; Gilkson Miryam, et al., “Relapsing Hepatitis A. Review of 14 cases and literature survey,” Medicine, Vol. 71, No. 1, 14-23 (Jan. 1992). Abstract of article online at http://www.ncbi.nlm.nih.gov/pubmed/1312659.

[38]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[39]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[40]          CDC, “Hepatitis A,” supra note 5; Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[41]          Gilkson Miryam, et al., “Relapsing Hepatitis A. Review of 14 cases and literature survey,” supra note 37.

[42]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Gilkson Miryam, et al., “Relapsing Hepatitis A. Review of 14 cases and literature survey,” supra note 37.

[43]          Mayo Clinic Staff, “Hepatitis A,” supra note 1.

[44]          CDC Summary, “Disease Burden from Viral Hepatitis A, B and C in the United States, 2004-2009, at http://www.cdc.gov/hepatitis/pdfs/disease_burden.pdf; CDC, “Hepatitis A,” supra note 5.

[45]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” World Journal of Gastroenterology, Vol. 12, No. 46 pp. 7405-7412 (Dec. 14, 2006). Full article is available online at http://www.wjgnet.com/1007-9327/12/7405.pdf.

[46]          Taylor, Ryan, et al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” Hepatology, Vol. 44, 1589-1597. Full text http://deepblue.lib.umich.edu/bitstream/2027.42/55879/1/21349_ftp.pdf.

[47]          Id.; See also Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[48]          Taylor, Ryan, et. al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” supra note 46.

[49]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[50]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Schiff, E.R., “Atypical Manifestations of hepatitis-A,” supra note 23.

[51]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45.

[52]          Id.; See also Taylor, Ryan, et. al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” supra note 46.

[53]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45; Taylor, Ryan, et. al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” supra note 46.

[54]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45.

[55]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45; Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1.

[56]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45.

[57]          Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management,” supra note 45; Taylor, Ryan, et. al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” supra note 46.

[58]          Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” supra note 1; Jaykus Lee Ann, “Epidemiology and Detection as Options for Control of Viral and Parasitic Foodborne Disease,” supra note 12.

[59]          CDC, “Update: Prevention of Hepatitis A after Exposure to Hepatitis A Virus and in International Travelers, Updated ACIP Recommendations,” Morbidity and Mortality Weekly Report, Vol. 56, No. 41, pp. 1080-84 (Oct. 19, 2007), online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a3.htm.

[60]          CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13; Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” supra note 7.

[61]          CDC, Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States,” supra note 44; CDC, “Hepatitis A,” supra note 5.

[62]          Hutin YJF, et al., “A Multistate, Foodborne Outbreak of Hepatitis A,” supra note 16.

[63]          CDC, Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States,” supra note 44; CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13.

[64]          CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13; Schiff, E.R., “Atypical Manifestations of hepatitis-A,” supra note 23.

[65]          CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13.

[66]          Id.

[67]          Id.

[68]          CDC, Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States,” supra note 44.

[69]          CDC, “Surveillance for Acute Viral Hepatitis – United States 2007,” supra note 13; CDC, “Hepatitis A,” supra note 5.

[70]          CDC, “Hepatitis A,” supra note 5; Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations,” supra note 20.